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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fR 0012 3� �q <br /> OWNER/OPERATOR <br /> ) ,D `- CHECK If BILLING ADDRESS <br /> FACILITY NAME ` C' \VZO C \ \vim 'Dbk \CL t C�'�o (,L,y�G e ) v1s <br /> SITE ADDRESS q 2;,5 N "t t\• Sj- I N" n 'LCs- 0 5-:13 G <br /> Street Number Dlreotion I Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) / [a 1;fps T1 t(�, <br /> 32 L1 "' O CG✓�\Q t-t Street Number L � Street Name 3 <br /> CITY STATE ZIP <br /> PHONE#t EaT APN# LAND USE APPLICATION# <br /> (70"3) 3Co2 <br /> PHONE ExT BOS DISTRICT LOCATION CODE <br /> ( ) 2 13 41+ 99 33 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR/-�` <br /> It ))'S�V, � v{„�(�t,JZCp CHECK If BILLING ADDRESS <br /> BUSINESS NAME V PHONE# En. <br /> enc LP 1tt�o ��y,� � 36Z ��z <br /> HOME or MAILING ADDRESS FAX# <br /> 3 l-1-+ e o ramal e. ( ) <br /> CITY Co"(2 STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. / <br /> 114PPLICANT'S SIGNATURE: —�� DATE: <br /> � c r� <br /> PROPERTY/BUSINESS OWNEFQ OPERATOR/MANAGER to, OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. n P <br /> TYPE OF SERVICE REQUESTED: Pit <br /> COMMENTS: t iIV 9 0 20 <br /> COU <br /> 'NFNT <br /> ACCEPTED BY: r/1 EMPLOYEE M DATE: <br /> ASSIGNED TO: I Y V EMPLOYEE#: DATE: J <br /> Date Service Competed (if already completed): SERVICE CODE: ( -FP/E-. <br /> ( UZ <br /> Fee Amount: 410-z— Amount Pai 6:2 0& I <br /> Payment Date &13012-1 30 Z <br /> Payment Type Invoice# Check# Z772� 771 Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �n I�I Ole S <br />